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I hereby authorize the doctor or designated staff to take X-rays, study models, photographs, and any other diagnostic aids deemed appropriate by the doctor to make a thorough diagnosis of my dental needs. I authorize the doctor to perform all recommended treatment mutually agreed upon and to employ such assistance as required. I agree to the use of anesthetics, sedatives, and other medications as necessary and understand the risks involved.
I agree to be responsible for the payment of all services rendered on my behalf or for my dependents. I understand that payment is due at the time of service unless prior arrangements have been made. I also understand that a 1.5% late charge (18% APR) and collection/legal fees may apply for overdue balances.
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